Clinical outcomes of adaptive intracavitary and interstitial brachytherapy technique in locally advanced cervical cancer: A real-world data

PURPOSE

To evaluate clinical outcomes of CT-based adaptive intracavitary and interstitial brachytherapy (IC followed by IC-ISBT) in locally advanced cervical cancer (LACC) in resource-constrained settings.

METHODS AND MATERIALS

LACC patients treated with adaptive brachytherapy techniques were analyzed to evaluate treatment characteristics and clinical outcomes. The Kaplan-Meier method was used for survival analysis, and the log-rank test for univariate analysis.

RESULTS

Out of 141 eligible patients with LACC, 87 (61.7%) patients received external beam radiotherapy (EBRT) in referral hospitals, while 54 (38.3%) were treated at our center. We divided our cohort into two groups: poor EBRT responder group (n = 70 [49.6%]) where IC-ISBT was adapted to achieve optimum tumor doses and OAR optimization group 71 (50.4%) where IC-ISBT was performed to reduce OAR doses. Median HRCTV-D90 dose was 88 Gy (range 70-109 Gy) with median HRCTV volume 33cc (range 15-96). Median D2cc doses to OARs were 90 Gy (range 70-107), 71 Gy (range 55-105) and 70 Gy (range 47-90) to bladder, rectum and sigmoid, respectively. At median follow-up of 32 months, 3-year local control (LC), locoregional control (LRC), disease-free survival (DFS) and overall survival (OS) were 83%, 75%, 64% and 72%, respectively. Subgroup analysis revealed significantly better outcomes for OAR optimization compared to poor EBRT responders, with 3-year LC (95% vs. 70.1%, p < 0.001), LRC (87.3% vs. 62.7%, p < 0.001), DFS (79.2% vs. 49.4%, p < 0.001), and OS (86.2% vs. 57.4%, p < 0.001) CONCLUSION: In resource-constrained settings, implementation of Adaptive IC-ISBT is a viable alternative for optimizing OAR doses in LACC. However proactive approach employing IC-ISBT for tumor dose-escalation from first fraction of BT is warranted for improving LC in poor EBRT responders.

Clinical Implementation of "Plan of the Day" Strategy in Definitive Radiation Therapy of Cervical Cancer: Online Adaptation to Address the Challenge of Organ Filling Reproducibility

PURPOSE

Definitive pelvic intensity modulated radiation therapy (IMRT) in cervical cancer is susceptible to geographic miss due to daily positional and volumetric variations in target and organs at risk. Hence, despite evidence of reduced acute and late treatment-related toxicities, implementation of image-guided IMRT (IG-IMRT) with a reasonable safety margin to encompass organ motion is challenging.

METHODS AND MATERIALS

In this prospective, nonrandomized phase 2 study, patients with cervical cancer International Federation of Gynecology and Obstetrics (2009) stage IB2-IIIB between the ages of 18 and 65 years were treated with definitive pelvic chemoradiotherapy with a prespecified organ (bladder and rectum) filling protocol. Reproducibility of organ filling was assessed along with the implementation of daily comprehensive adaptive image-guided radiotherapy (IGRT), with a library of 3 IMRT (volumetric modulated arc therapy) plans with incremental expansions of clinical target volume (CTV) to planning target volume (PTV) (primary) margins (small, 0.7 cm; adequate, 1 cm; and large, 1.5 cm) and a backup motion robust 3-dimensional conformal radiotherapy plan; the appropriate plan is chosen based on pretreatment cone beam computed tomography (CBCT) ("plan of the day" approach).

RESULTS

Fifty patients with a median age of 49 years (IQR, 45-56 years) received definitive radiation therapy (45-46 Gy in 23-25 fractions to pelvis, with simultaneous integrated boost to gross nodes in 15 patients) with the aforementioned IGRT protocol. In the analysis of 1171 CBCT images (in 1184 treatment sessions), the mean planning computed tomography (CT) and CBCT bladder volumes were 417 and 373 cc, respectively. Significant interfractional variation in bladder volume was noted with a mean absolute dispersion of 29.5% with respect to planning CT; significant influential random factors were postchemotherapy sessions (P ≤ .001), pre-CBCT protocol duration (P = .001), and grades of chemotherapy induced nausea vomiting (P = .001). Significantly higher variation in bladder filling was noted in patients with older age (P = .014) and larger planning CT bladder volume (P ≤ .001). Time trend analysis of fraction-wise bladder volume revealed an absolute systemic reduction of 16.3% in bladder volume means from the first to the fifth week. Variation in rectal diameter was much less pronounced, with 19.2% mean dispersion and without any significant factors affecting it. Although in 19% and 2% of sessions large IMRT PTV and 3-dimensional conformal radiotherapy were necessary to cover the primary target, respectively, reduction in treated volume was possible in 43% of sessions with small PTV selection instead of standard adequate PTV (36% sessions). Plan of the day selection had a moderate to strong correlation with nonabsolute dispersion of bladder filling (Spearman ρ =0.4; P = .001) and a weak (but significant) correlation with grades of acute toxicities. The planned protocol was well tolerated with no radiation-induced local grade 3 toxicity.

CONCLUSIONS

Interfractional variation in organ filling (especially bladder) is inevitable despite fixed pretreatment protocol in definitive settings (intact cervix). Despite the logistical challenges, adaptive IGRT in the form of plan of the day based on incremental CTV-to-PTV margins is a relatively simple and feasible strategy to minimize geometric uncertainties in radical IG-IMRT of cervical cancer.

Correlation of Hematological Parameters With Clinical Outcomes in Cervical Cancer Patients Treated With Radical Radio(chemo)therapy: A Retrospective Study

PURPOSE

Variations in the levels of systemic inflammatory biomarker levels have been linked with outcomes in various malignancies including cervical cancer. In this study, we investigated prognostic implications of pretreatment hematological factors/indices in locally advanced cervical cancers treated with radical radio(chemo)therapy.

METHODS AND MATERIALS

Electronic medical records of 1051 patients with cervical cancer of FIGO (International Federation of Gynecology and Obstetrics) stage IB2-IVA treated in various prospective trials at our institute between 2003 and 2017 were reviewed. All clinical parameters such as age (dichotomized at the median), stage (IB2-IIB vs III-IVA), histologic type (squamous vs others), and hematological parameters (hemoglobin, platelets, absolute neutrophil count, absolute lymphocyte count, absolute monocyte count) were recorded. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and prognostic nutritional index (PNI; defined as 10 × albumin concentration [g/dL] + 0.005 × total lymphocyte count [μL]) were calculated. Univariate and multivariate (Cox regression) analyses were performed to evaluate these factors with disease-free survival (DFS) and overall survival (OS).

RESULTS

With a median follow-up of 69 months, the 5-year DFS and OS were 65% and 69%, respectively. On multivariate analysis, FIGO stage (hazard ratio [HR], 1.9; P = .000) and PLR (HR, 1.002; P = .008) significantly affected DFS while FIGO stage (HR, 1.804; P = .000), LMR (HR, 0.92; P = .018), PNI (HR, 0.96; P = .013), and PLR (HR, 1.002; P = .006) significantly affected OS. Apart from FIGO stage, PLR significantly affected both DFS and OS. This correlation of hematological parameters is stronger in stage IIIB cervical cancer.

CONCLUSIONS

Hematological indices, including PNI, PLR, and LMR, can serve as reliable prognostic indicators for patients with cervical cancer. By incorporating these indices into routine assessment and monitoring, clinicians can better stratify patients, personalize treatment plans, and more accurately predict outcomes, ultimately improving patient care and management.

Reirradiation with advanced brachytherapy techniques in recurrent GYN cancers

PURPOSE

To evaluate clinical outcomes of recurrent gynaecological cancers treated with reirradiation (reRT) using advanced brachytherapy (BT) technique.

METHODS AND MATERIALS

Seventy-six women who underwent reRT with BT for gynaecological cancers at our institute between January 2000 and December 2019 were analysed to determine patient, disease and treatment characteristics and clinical outcomes. Descriptive analysis was used for demographics, and the Kaplan Meir method was used for survival analysis.

RESULTS

Median age at recurrence was 55 years (Range: 35-73). Forty-three patients had recurrent cervical cancer with intact uterus, and 33 had recurrent vault/vaginal cancers post adjuvant RT. Eight patients received EBRT prior to BT (Range: 30-50Gy). Twenty-two patients (28.9%) received salvage chemotherapy before consideration of brachytherapy. Brachytherapy application was done using MUPIT in 38, Vienna applicator in 20, Syed Neblett in 8, central vaginal cylinder in 3, multicatheter intravaginal applicator in 2, tandem-ovoids in 4 and Houdek applicator in 1 patient. Median cumulative EQD2 for all courses of radiation was 108 Gy (IQR 92-123 Gy). At median follow up of 39 months, local control (LC), progression-free survival (PFS) and Overall survival (OS) at 2-years was 60%, 56.3%, and 72.9 respectively. Patients who had recurrences beyond 2 years had significantly better OS compared to early recurrences. Patients who received BT doses >40 Gy had a higher LC and PFS. Grade 3 to 4 late rectal toxicity was seen in 10 (13%), bladder toxicity in 6 (8%) and vaginal fibrosis in 24 (31%) patients.

CONCLUSION

The use of advanced BT approach in reirradiation setting is a feasible and safe option in treatment of post-treatment recurrent cervical, endometrial, and vaginal cancers.

Sigmoid dose accumulation and reporting for multifractionated brachytherapy for cervical cancer: Methodological development of sigmoid points through virtual endoscopic method

PURPOSE

The sigmoid is an important organ at risk for gynecological brachytherapy (BT). However, the reliability of localization of high-dose regions during multi-fractionated treatment is limited. This work reports the methodological development of sigmoid points to summate multi-fractionated doses.

METHODS AND MATERIAL

Ten paired MRI data sets of ring-based intracavitary brachytherapy were obtained. Simulating a virtual endoscope, a reference line was created along the central axis of the anorectosigmoid for each implant. A trendline was generated, and linear dose was determined. Three-dimensional (3D) coordinates of high-dose regions were identified, and overlap was determined. In the next step, 3D coordinates of high-dose sigmoid points were localized in reference to cervical os and re-verified for location in reference to sigmoid lumen and corroboration with 2cc doses. With minor modifications, sigmoid points were proposed.

RESULTS

In 6 of 10 patients, high-dose regions co-localized in subsequent fractions of BT. Three high-dose regions were identified along the sigmoid length and proposed as sigmoid points in reference to cervical os. (S1'= 0.5 cm right, 1.5 cm posterior, and 2.4 cm cranial; S2' = 0.3 cm anterior and 4.5 cm cranial; S3' = 2.7 cm left, 3 cm anterior, and 3.6 cm cranial to the cervical os). S1' and S2' were located in the sigmoid in 70% and 60% of data sets. The mean difference between D2cc and S1'/S2' was 0.30 Gy and 1.06 Gy respectively. S3' had limited corroboration to sigmoid lumen or 2 cc doses. The points S1' and S2' were further modified (minor) for applicability and proposed as sigmoid points 1 and 2 (SP1 0.5 right,1.5 posterior and 2.5 cm cranial to cervical os and SP2 (0.5 cm anterior and 4.5 cm cranial to cervical os)).

CONCLUSION

SP1 and SP 2 are proposed as a surrogate for 2 cc sigmoid doses and may provide a method of reliable inter-fraction dose summation. This pilot work requires further validation.

Early outcomes of abbreviated multi-fractionated brachytherapy schedule for cervix cancer during COVID-19 pandemic

PURPOSE

Brachytherapy (BT) for cervix cancer was listed as a level I priority and reduced number of implants and multiple fractions were recommended during COVID-19 pandemic. We present early clinical outcome of this approach.

METHODS AND MATERIALS

Patients treated with (chemo)radiotherapy and BT with single implant and multiple fractions BT were included. Treatment protocol included 3-5 fractions of 5-8.5 Gy with an aim to achieve point A dose of 70 Gy EQD2_10Gy (or HRCTV dose of >80 Gy EQD2_10Gy) in those undergoing intracavitary (IC) and HRCTV dose >85 Gy EQD2 10Gy in patients undergoing Intracavitary-Interstitial (IC/IS) whereas maintaining bladder (B2cc), rectum (R2cc), sigmoid (S 2cc) doses of 90, 75, and 75 Gy EQD2_3Gy. Time to event analysis was used to report oncological endpoints. Toxicity was reported using crude proportions.

RESULTS

From April 2020 to March, 2021, 64 patients with stage IB2-IV received single implant and multi-fraction BT after external radiation of 45 Gy/25 fractions/5 weeks. Only 76.7% (n = 49) received concurrent chemotherapy. Median overall treatment time (OTT) was 56 days (38-131 days). Overall, 62.5% (n = 40) patients received IC and 37.5% (n = 24) received IC+IS. The median HRCTV was 34.7 cc (IQR 25-41). Median (IQR) point A dose, HRCTV D90, B2cc, R2cc, and S2cc for those undergoing IC was 74 Gy (71-78), 80 Gy (73-84), 86 Gy (82-89), 70 Gy (65-74), 65 Gy (59-73) respectively. For the IC+IS cohort, HRCTV D90, B2cc, R2cc, and S2cc was 84 Gy (78-89 Gy), 89 Gy (86-92), 70 Gy (67-74), 68 Gy (59-76). At a median follow-up of 16 months (5-27) the 2-year local control, pelvic control, cause specific and overall survival was 88%, 85.3%, 92.2%, and 81.3% respectively. Late gastrointestinal and genitourinary grade ≥III toxicities were 14% and 1.5% each.

CONCLUSIONS

Abbreviated BT outcomes are encouraging for oncological outcomes despite delays in overall treatment time and omission of chemotherapy. Further mature follow up is needed.

Months and Severity Score (MOSES) in a Phase III trial (PARCER): A new comprehensive method for reporting adverse events in oncology clinical trials

BACKGROUND

Adverse event reporting in oncology trials lacks temporal description. We propose a toxicity summarizing method that incorporates time.

METHODS

Patients recruited in a phase III trial (NCT01279135) that compared three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) for late toxicity in cervical cancer were included. Adverse events were reported using Common Terminology Criteria for Adverse Events (CTCAE) v3.0 and quality of life (QOL) with EORTC QLQ-C30 and CX24. A total of six symptoms with a related QOL question (diarrhoea, abdominal pain, anorexia, urinary incontinence, frequency and fatigue) were included. Month and severity score [MOSES= ∑ (CTCAE grade x proportionate time)] was calculated. Cumulative-MOSES (C-MOSES) was calculated by summating these 6 individual MOSES. QoL was categorized as "substantially symptomatic" or "not". Receiver operator curve analysis was performed to determine the MOSES cut off that predicts for substantial QOL symptoms. CTCAE and MOSES were tested for accurately categorizing QOL impact.

FINDINGS

In the construction dataset, 201/300 patients had symptoms. MOSES > 0.20 had higher accuracy than CTCAE for predicting impact on QOL related to diarrhoea (85% vs. 69%), anorexia (61% vs 51%), abdominal pain (71% vs. 57%), urinary incontinence (72% vs. 61%) and frequency (62% vs. 59%). C-MOSES > 0·70 correlated with reduction in role functioning and global QOL. While no difference was seen in CTCAE grade ≥1 Gastrointestinal (GI) toxicity between 3DCRT or IMRT arm, 3DCRT had higher C-MOSES than IMRT (HR=0.64;95% CI 0.41-0.99, p = 0.04).

INTERPRETATION

MOSES has higher accuracy than CTCAE in categorizing symptom specific and functional QOL. These results require further external validation.

FUNDING

None.

Knowledge, Attitudes and Practices Towards COVID-19: A Cross-Sectional Survey

Aim

To assess the knowledge, attitudes and practices (KAP) regarding the corona virus disease 2019 (COVID-19) pandemic among patients and their attendants visiting the gynaecologic oncology outpatient department (OPD) and to assess the factors associated with a KAP score.

Methodology

A KAP cross-sectional survey was conducted over three months exploring KAP relevant to COVID-19. Mann–Whitney U test and Kruskal–Wallis test were used to compare the differences in knowledge, attitude and practice by demographic characteristics. Correlation between knowledge, attitude and practice was done using Spearman’s rank correlation test. Binary logistic regression analyses were applied to identify possible determinants of good knowledge, attitude and practice.

Results

A total of 521 completed questionnaires were included. The study revealed an overall good knowledge (16.09/20), attitude (8.34/10) and practice (12.73/14) scores. Education status, standard of living (rural/urban) and economic status determined an adequate overall knowledge, attitude and practice score, while an adequate practice score varied significantly by standard of living and education status. Significant positive linear correlations were found between knowledge–attitude (r = 0.513), knowledge–practice (r = 0.407) and attitude–practice (r = 0.407).

Conclusion

The study demonstrated good overall knowledge, attitude and practices towards COVID-19 pandemic among gynaecological oncology OPD patients and their attendants.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40944-022-00624-1.

Outcomes of Cervical Cancer in HIV-Positive Women Treated With Radiotherapy at a Tertiary Care Center in India

There are limited data on management of cervical cancer in women living with HIV in the modern antiretroviral therapy era. The study aimed to evaluate outcomes and toxicities of these patients treated with radiotherapy.

Gynecologic radiation therapy in low and middle income countries during the COVID-19 pandemic

The COVID-19 pandemic has forever affected healthcare and posed an incredible challenge to our society to care for our sick. Patients with cancer were found early on to have higher rates of complications with COVID-19. Radiation therapy is an integral part of treatment for many types of gynecologic cancer and adaptation on its utilization during the pandemic varied across the globe. In this review, we detail certain guidelines for the use of radiation in gynecologic cancers during the pandemic as well as real world accounts of how different countries adapted to these guidelines or created their own based on individualized resources, staffing, government restrictions, and societal norms. Critically, this review demonstrates the breadth of fractionation schemes and technologies used when resources were limited but highlights the importance of long term follow-up for many of our patients during this time.

The state of gynecologic radiation therapy in low- and middle-income countries

A disproportionate burden of gynecologic malignancies occurs in low- and middle-income countries. Radiation therapy is an integral component of treatment for gynecologic malignancies both from a curative (locally advanced cervical cancer) and palliative (bleeding cervical or pelvic mass) standpoint. Critical to understanding how better to serve patients in this regard is understanding both the extent of disease epidemiology and the radiotherapy infrastructure to treat these diseases. In this review, we explore various geographic regions and how they address a unique set of challenges specific to the peoples and culture of the region. We identify common threads across regions, including sparse distribution of radiation equipment, geographic access, and specialized training. We also highlight examples of success in the use of telemedicine and cross-cultural partnerships to help bolster access to training to ensure increased access to adequate and appropriate treatment of gynecologic malignancies.

Compliance of Radiotherapy Treatment at a Tertiary Cancer Center in India—A Clinical Audit

Introduction Noncompliance to planned radiotherapy (RT) treatment is associated with inferior outcomes and also serves as an indicator of quality of care offered to the patients. Identification of the rate of noncompliance and its causative factors can help us develop an insight toward implementing mitigation measures thereby improving the quality of treatment.

Objective To ascertain the incidence of noncompliance and the factors affecting the same in patients offered RT appointments.

Materials and Methods We retrospectively reviewed the records of patients from January 1, 2019, to December 31, 2019, who were noncompliant (defaulted RT simulation or defaulted initiation of RT or defaulted planned RT during the course of RT but excluding planned/unplanned treatment breaks or early conclusions prescribed by the treating radiation oncologist) for the planned RT treatment.

Results Of the 8,607 appointments (7,699 external beam RT and 908 brachytherapy) given to the patients attending the radiation oncology outpatient department in the year 2019, a total of 197 (2.28%) patients were found to be noncomplaint. Ninety-seven patients defaulted RT simulation (49.2%), 53 defaulted RT starting (26.9%), and 47 defaulted while on RT (23.9%). Half of these had either head–neck (29.9%) or gynecological (20.8%) malignancies. Patients with breast cancers had the least noncompliance rates (0.02%). The cause for noncompliance was ascertained in 135 patients (68.5%). The common causes of noncompliance were the desire to continue treatment closer to home (21.5%) followed by logistic (17%), lack of confidence in the curative potential of the planned therapy (17%), and financial reasons (11.8%). Patients with head–neck and gynecological malignancies were more often with advanced staged disease and were planned multimodal treatment protocols. The majority of the 23 patients who defaulted palliative RT were planned for fractionated treatments (73.9%).

Conclusion The incidence of noncompliance in patients planned for RT in our institute can be considered optimum. Appropriate counseling of patients at the time of scheduling appointment, upfront identification of patients at high risk of noncompliance, and assisting patients with financial and logistic challenges are imperative to ensure adherence to planned treatment schedule.

Patterns of relapse after adjuvant (chemo)radiation for cervical cancer in a phase III clinical trial (PARCER): an evaluation of updated NRG Oncology /RTOG target delineation guidelines

AIM

NRG Oncology/RTOG recently published updated contouring guidelines for intensity modulated radiotherapy in postoperative treatment for endometrial and cervical cancer. The present study was designed to evaluate the implications of newly published guidelines.

METHODS

Patients (n = 300) recruited in Phase III RCT of adjuvant (chemo)RT for cervical cancer (NCT01279135) were included for understanding patterns of relapse. For those with pelvic relapse, RT structure sets, treatment plans and diagnostic images at relapse were imported on the treatment planning system. Rigid registration was performed with treatment planning images that contained the delineated PTV and radiation dose information. Gross tumor volume at time of relapse was delineated on the diagnostic scans and superimposed on the radiotherapy treatment scans. The site of pelvic relapse was categorized as "within field of old RTOG/PARCER target delineation guidelines" or/and "within field of new NRG/RTOG guidelines" and proportions of recurrences contained within the two guidelines were compared. p-value of <0.05 was considered statistically significant. Additionally, IMRT treatment plans were generated based on the new guidelines for a limited set of patients to see if these new guidelines increased the organ at risk doses.

RESULTS

Most common form of relapse was distant metastasis (15%). Pelvic relapse rate in our study was 8%. Overall 9/19 relapses were encompassed in the old RTOG/PARCER contouring guidelines while 12/19 were encompassed within the new RTOG 2021 contouring guidelines. This corresponded to a further 1% reduction in local relapses (p 0.007). Dose to rectum was marginally increased with the new contouring, with no difference in other organs at risk. Salvage treatment was offered in 25/60 patients who relapsed. In patients who received local treatment after relapse had a mean survival after relapse of 27.2 months compared to 8 months who received supportive care alone.

CONCLUSION

Our study supports the use of newly published NRG/RTOG contouring guidelines in patients with cervical cancer who have undergone hysterectomy. Further data is needed to ascertain if anterior extension of the CTV is needed as in PARCER trial.

Temporal course of late rectal toxicity & impact of intervention in patients undergoing radiation for cervical cancer

Background & objectives:

There is limited information available on the temporal course of late stage radiotherapy adverse effects. The present study reports on the temporal course of late toxicities after chemoradiation and brachytherapy.

Methods:

Women with cervical cancer who presented with late toxicity after (chemo) radiation were included in the study. Grade of toxicity (Clinical Toxicity Criteria for Adverse Events version 4.03) and type of intervention were recorded at three-monthly interval for the first year and then six monthly until 24 months. Direct cost for the management of toxicity was calculated. Univariate analysis was performed to understand the impact of various factors on persistence of toxicity.

Results:

Ninety two patients were included in this study. Grades I, II, III and IV toxicities were observed in 50 (54%), 33 (36%), 7 (8%) and 2 (2%) patients, respectively, at first reporting. Patients spent a median of 12 (3-27) months with toxicity. At 12 months, 48/92 (52.2%) patients had a complete resolution of toxicity, whereas 27/92 (29.3%) patients had low grade (I-II) persistent toxicity. Only 6/92 (6.5%) patients who had grade III−IV toxicity had resolution to a lower grade. Four (4.3%) patients died due to toxicity. At 24 months, 9 (10%) patients continued to have grade ≥ III toxicity. On an average, 7 (2-24) interventions were required for the clinical management of late toxicity and median direct cost incurred was ₹ 50,625 (1,125-303,750).

Interpretation & conclusions:

In this study late radiation toxicity resolved within 12 months in more than half of patients. However, others are likely to have had persistent lower grade toxicity or progression to higher grade. Structured strategies are hence needed for the effective management of late toxicities.

Dosimetric impact of target definition in brachytherapy for cervical cancer – Computed tomography and trans rectal ultrasound versus magnetic resonance imaging

•

This study evaluated the dosimetric impact of target volume delineation in Computed Tomography (CT) with assistance from Trans Rectal Ultrasound (TRUS) as compared to Magnetic Resonance Imaging (MRI) image-based brachytherapy for cervical cancer.

•

No statistically significant systematic difference was found between MRI and CT for target structures.

•

However, considerable variations were seen on individual patient level which needs to be considered during clinical practice, which also needs further investigations.

•

Current findings provide useful information to optimally utilize various imaging modalities for brachytherapy planning.

•

Although, CT + TRUS based delineation of target volume, appear promising, MRI remains the gold standard.

Background and Purpose

Magnetic Resonance Imaging (MRI) based target definition in cervix brachytherapy is limited by its availability, logistics and financial implications, therefore, use of computed tomography (CT) and Trans Rectal UltraSonography (TRUS) has been explored. The current study evaluated the dosimetric impact of CT + TRUS based target volumes as compared to gold standard MRI.

Methods and Materials

Images of patients (n = 21) who underwent TRUS followed by MRI and CT, were delineated with High-Risk Clinical Target Volume in CT (CTV_HR-CT) and in MRI (CTV_HR-MR). CTV_HR-CT was drawn on CT images with TRUS assistance. For each patient, two treatment plans were made, on MRI and CT, followed by fusion and transfer of CTV_HR-MR to the CT images, referred as CTV_HR-MRonCT. The agreement between CTV_HR-MRonCT and CTV_HR-CT was evaluated for dosimetric parameters (D₉₀, D₉₈ and D₅₀; Dose received by 90%, 98% and 50% of the volumes) using Bland-Altman plots, linear regression, and Pearson correlation.

Results

No statistically significant systematic difference was found between MRI and CT. Mean difference (±1.96 SD) of D₉₀, D₉₈ and D₅₀ between CTV_HR-MRonCT and CTV_HR-CT was 2.0, 1.2 and 5.6 Gy respectively. The number of patients who have met the dose constraints of D₉₀ > 85 Gy were 90% and 80% in MR and in CT respectively, others were in the borderline, with a minimum dose of 80 Gy. The mean ± SD dose-difference between MR and CT plans for bladder was significant (5 ± 13 Gy; p = 0.12) for D_0.1cm3, while others were statistically insignificant.

Conclusion

CT + TRUS based delineation of CTV_HR appear promising, provide useful information to optimally utilize for brachytherapy planning, however, MRI remains the gold standard.

Effect of COVID-19 Pandemic on Gynecological Cancer Radiation During Complete Nationwide Lockdown: Observations and Reflections From Tertiary Care Institute in India

PURPOSE

To report real-world compliance to radiation in gynecologic cancers during the complete lockdown phase of COVID-19 pandemic.

METHODS AND MATERIALS

From March 23, 2020, until June 30, 2020, complete lockdown was imposed in India. During this period there was restructuring of cancer care and radiation oncology department due to operational policies prevalent in the institution, and the care for gynecological cancer was based on the evolving international recommendations. Institutional review board approval was obtained to audit patterns of care during the complete lockdown phase. Descriptive variables were used to report on patient characteristics, compliance, delays, toxicity, and observed deviations in recommended care.

RESULTS

During the lockdown period spanning 100 days, treatment of 270 and telephonic follow-up of 1103 patients with gynecological cancer was undertaken. Of 270 new patients, due to travel restrictions, 90 patients were referred to the facilities in vicinity of their residence. Of the remaining 180 patients, 138 were planned for complete treatment at our institution and 42 were referred to our center for brachytherapy. Of 138 patients, only 106 (76%) completed the planned external radiation. Twenty-four (26%) patients completed full course of concurrent chemotherapy, 11 (12%) received chemotherapy dose reduction, and 57 (62%) received no concurrent chemotherapy. Treatment delay of up to 3 weeks was noted in 8.6% patients due to COVID-19 infection. No grade 4 to 5 acute sequelae were observed. No excess adverse effects were observed in high-risk population. Low rate of symptom burden was observed among 1103 patients on telephonic follow-up. With 100 (9.6%) patients reporting symptoms, among these, 54% (54 of 100) had complete resolution of symptoms within 4 weeks of teleconsultation, and 10% had disease progression.

CONCLUSIONS

Low compliance with planned treatment was observed for radiation and concurrent chemotherapy due to lockdown and fear of contracting COVID-19 and will likely lead to increased risk of cancer-related mortality. Rapid restructuring of care is needed to prevent the same as COVID-19 pandemic further evolves.

Low-Dose-Rate versus High-Dose-Rate intracavitary brachytherapy in cervical cancer - Final Results of a Phase III randomized trial

PURPOSE

Intracavitary brachytherapy using High-Dose-Rate (HDR) and Low-dose-rate (LDR) in cervical cancer has been utilized. We report the long-term final results of a large randomized trial in terms of toxicities and efficacy.

METHODS AND MATERIALS

Between 1996 to 2005, 816 patients were randomized to LDR (n = 441 patients) or HDR brachytherapy (n = 369 patients) stratified by FIGO Stage grouping. Patients with Stage I-II received external irradiation of 40 Gy in 20 fractions (with midline block (MLB)) followed by either 2 LDR Intracavitary applications of 30 Gy to point A (2-3 weeks apart) or 5 HDR Intracavitary applications of 7 Gy to point A once weekly. Patients with Stage III received 50 Gy in 25 fractions (with MLB after 40 Gy) followed by either one application of LDR 30 Gy to point A or three applications of HDR 7 Gy to point A once weekly.

RESULTS

With a median follow-up was 64 months (interquartile range [IQR]: 21 - 111), moderate to severe rectal and bladder complications were higher in LDR arm as compared to HDR arm (9.7% vs. 3.6%; p = 0.02) and (10.5% vs. 5.5%; p = 0.06) for Stage I-II. No difference in rectal or bladder complications for Stage III patients. Disease free and overall survivals were similar in both the arms for all stages.

CONCLUSIONS

HDR intracavitary brachytherapy with 7 Gy per fraction weekly is superior to LDR in terms of late rectal and bladder complications. Local control rates and survivals are similar irrespective of stages.

Outcomes of Palliative Radiotherapy in Metastatic Epidural Spinal Cord Compression in Lung Cancer-A Prospective Observational Study from Tata Memorial Hospital

Background Metastatic epidural spinal cord compression (MESCC) secondary to lung cancer (LC) is a debilitating complication associated with poor prognosis and is commonly treated with radiotherapy (RT). There is no consensus for RT dose fractionation in spinal cord compression.

Methods Forty consecutive patients of LC with radiological evidence of MESCC treated with palliative RT were evaluated for functional outcomes (pain, ambulation, and sphincter function) at 2-, 4-, and 24-week post RT completion. Pain assessment was done using visual analogue scale (VAS) and response was categorized according to international consensus criteria, ambulation status (AS) using Tomita’s scale, and sphincter function by the presence or absence of a catheter. Overall survival (OS) was assessed using Kaplan-Meier method and compared using log-rank test. Impact of potential prognostic factors on survival was also analyzed and p -value ≤0.05 was considered significant.

Results Sixteen, 22, and two patients received 8 Gy single fraction (SF), 20 Gy in five fractions (20/5), and 30 Gy in 10 fractions (30/10), respectively. At 2 weeks, overall response (OR) rates of pain, ambulation, and sphincter control were 73, 81, and 81%, respectively. At 4 and 24 weeks, 93.7, 84.3, 87.5% and 88, 94, 76.5% had OR, respectively. Median OS was 4 months. Six- and 12-months OS was 50 and 37.5%. Nonsignificant difference in OS was seen between SF and 20/5 fractions (median 2.2 vs. 7.1 months, p = 0.39). Age ≤50 years was the only significant factor ( p <0.05) in univariate analysis for OS.

Conclusion Radiotherapy provided equivalent pain control, ambulation, and sphincter function compared with reported literature in MESCC. Nonsignificant difference in OS exists between SF and multifraction RT regimens.

Meeting the Global Need for Radiation Therapy in Cervical Cancer-An Overview

Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women. The discrepancy in cervical cancer incidence and mortality between developed and developing nations has become increasingly apparent with 84% of the incidence and 88% of the mortality of cervical cancer occurring in low income countries. Access to comprehensive cancer care is a challenge and in particular the radiotherapy facilities. The radiotherapy infrastructure requirement is grossly inadequate with only 30% of the needs available and is even worst in LIC's with only 3% facilities. Additionally, lack of brachytherapy facilities and expertise in LIC's and LMIC's compounds the issue further. Even with continued HPV vaccination programs, there will still be a substantial burden of cervical cancer patients for treatment. Introspection and review in international and national policies, augmentation of (i) infrastructure - affordable & sustainable, (ii) manpower and rigorous training in accessible regions would be vital. International and National collaborative efforts among global organizations and societies, periodic peer reviews, resource stratified treatment guidelines and research, and health education would contribute further to women health. The amalgamation of palliative and hospice care services and radiotherapy facilities seamlessly would be a major step for comprehensive management of cervical cancer patients.

Cervical Cancer Treatment in HIV-Positive Patients: A Survey of Treatment Practices in India

Chemoradiation remains a challenge in women living with HIV (WLWH) and cervical cancer primarily because of concerns regarding immune status. With limited literature available to help guide the management of these patients, clinical practices among oncologists are variable across India. Hence, we conducted a survey among radiation oncologists in India to assess the patterns of current practices of treating cervical cancer with chemoradiation in WLWH.

Para-aortic lymph node involvement in cervical cancer: Implications for staging, outcome and treatment

Locally advanced cervical cancer with the involvement of para-aortic lymph nodes (PALN) is a common occurrence in low-income and low-middle-income countries. With the incorporation of PALN in the recent FIGO staging, therapeutic management becomes crucial. There are varied presentations of this group which may range from microscopic involvement to extensive lymphadenopathy. Various imaging modalities have been studied to accurately diagnose PALN metastases without surgical intervention, while some investigators have studied the survival benefit of para-aortic lymph node dissection for accurate staging and guiding extent of radiation. With recent advances in radiation therapy, its application to treat bulky nodal metastases and the role of prophylactic irradiation have been reported. In this review, the available evidence and the scope of further interventions is presented.

Single Application Multifractionated Image Guided Adaptive High-Dose-Rate Brachytherapy for Cervical Cancer: Dosimetric and Clinical Outcomes

PURPOSE

A prospective phase 2 study was conducted to evaluate the feasibility and safety of single-application multifractionated (SA-MF), high-dose-rate (HDR), image guided adaptive brachytherapy (IGABT) for cervical cancer.

METHODS AND MATERIALS

Patients (N = 41) with International Federation of Gynaecology and Obstetrics 2009 stage IIB-IVA disease recruited between 2017 and 2019 underwent SA-MF. After completion of external beam radiation therapy of 50 Gy in 25 fractions, patients received magnetic resonance IGABT. The IGABT protocol consisted of a single brachytherapy (BT) application and treatment with 3 fractions of HDR (9 Gy on day 1; 2 fractions of 7 Gy with a minimum 6-hour gap on day 2) after achieving planning aims of the high-risk clinical target volume (HRCTV) receiving >84 Gy EQD2 and 2 cm³ of the bladder and rectum/sigmoid receiving ≤85 Gy and <71 Gy, respectively. Interfraction variation was addressed by performing computed tomography planning and coregistration using a mutual information-based coordinate system on day 2 before the second fraction. Organ at risk contouring was done on computed tomography, and doses were re-evaluated and reoptimized if required.

RESULTS

Thirty-eight patients were treated as per the protocol. All patients underwent Intracavitary + Interstitial BT with needles (median, 4; range, 3-11). The mean ± standard deviation HRCTV volume was 41 ± 21 cm³ and HRCTV D90 dose was 87.2 ± 3.6Gy. The 0.1 cm³ and 2 cm³ to bladder, rectum, and sigmoid were -103.2 ± 10.6 Gy and -84.6 ± 6.8 Gy, 82.2 ± 9.5 Gy and -68.3 ± 5.7 Gy, and 83.5 ± 9.8 Gy and -69.5 ± 5.9 Gy, respectively. Six patients required reoptimization before the second fraction to meet planning aims. Mean overall treatment time was 47 ± 6 days. With a median follow up of 22 months (range, 2-37), 2-year local control and disease-free and overall survival were 90.1%, 85%, and 94.5%, respectively. So far 1 patient with grade II and 2 patients with grade III rectal toxicities have been reported.

CONCLUSION

Magnetic resonance IGABT with SA-MF BT was feasible in 95% of patients. The dosimetric parameters and clinical results achieved so far look promising.

Development and clinical validation of Knowledge-based planning for Volumetric Modulated Arc Therapy of cervical cancer including pelvic and para aortic fields

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A knowledge-based planning model was configured for VMAT of cervical cancer.

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Knowledge-based plans were comparable, and for some OARs, outperformed clinical plans.

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Improved organ sparing was observed, when individual patient geometry was considered.

Background and Purpose

Knowledge-based planning (KBP) is based on a model to estimate dose-volume histograms, configured using a library of historical treatment plans to efficiently create high quality plans. The aim was to report configuration and validation of KBP for Volumetric Modulated Arc Therapy of cervical cancer.

Materials and methods

A KBP model was configured from the institutional database (n = 125), including lymph node positive (n = 60) and negative (n = 65) patients. KBP Predicted plans were compared with Clinical Plans (CP) and Re-plans (Predicted plan as a base-plan) to validate the model. Model quality was quantified using coefficient of determination R2, mean square error (MSE), standard two-tailed paired t-test and Wilcoxon signed rank test.

Results

Estimation capability of the model was good for the bowel bag (MSE = 0.001, R2 = 0.84), modest for the bladder (MSE = 0.008) and poor for the rectum (MSE = 0.02 R2 = 0.78). KBP resulted in comparable target coverage, superior organ sparing as compared to CP. Re-plans outperformed CP for the bladder, V30 (66 ± 11% vs 74 ± 11%, p < .001), V40 (48 ± 14% vs 52 ± 14%, p < .001), however sparing was modest for the bowel bag V30 (413 ± 191cm³ vs 445 ± 208cm³, p = .037) V40 (199 ± 105cm³ vs 218 ± 127cm³, p = .031). All plans were comparable for rectum, while KBP resulted in significant sparing for spinal cord, kidneys and femoral heads.

Conclusion

KBP yielded comparable and for some organs superior performance compared to CP resulting in conformal and homogeneous target coverage. Improved organ sparing was observed when individual patient geometry was considered.

Reporting of dose-volume specifications for "Martinez Universal Perineal Interstitial Template-based interstitial high-dose-rate brachytherapy for gynecological cancers" according to International Commission on Radiation Units and Measurements 58 with early clinical outcomes

PURPOSE

The study is an audit of reporting dose and volume specifications as per the ICRU 58 for MUPIT-based interstitial brachytherapy in gynecological cancers. Correlation between total reference air kerma (TRAK) and isodose surface was also evaluated to understand the intensity of treatment in interstitial brachytherapy.

METHODS AND MATERIALS

Forty-two patients underwent HDR MUPIT-based interstitial brachytherapy 20 Gy in five fractions after EBRT during 2017-2019. Treated volume, high and low-dose regions, mean central dose, Dose Homogeneity Index (DHI), organ at risk doses, and TRAK values were computed.

RESULTS

High-dose regions V150 mean was 12.4 cc and V200 was 4.58 cc; and low-dose region was 75.92 cc. The mean treated volume was 59.8 cc. The mean central dose was 3.7 Gy. DHI was 79%. The mean D2cm³ bladder and rectum were 2.9 Gy and 2.8 Gy. The mean TRAK was 0.16 cGy per fraction per hour at 1 m. TRAK values showed significant correlation with various isodose volumes (TRAK and V100: r = 0.943 p < 0.0005; and TRAK and V50: r = 0.953; p < 0.0005). A positive correlation was observed between TRAK and the number of needles (r = 0.746; p < 0.0005). At a median followup of 16 months, 4 of 42 patients (9.5%) had local recurrences.

CONCLUSIONS

Our study shows compliance with ICRU 58 recommendations along with certain deviations. Local recurrence rate is acceptable. TRAK shows correlation with surface isodose in MUPIT-based brachytherapy and should to be evaluated in future studies.

Impact of COVID-19 on oncology education and training in India

Coronavirus disease-19 was declared a pandemic and global emergency in March 2020. Oncology education and training has been on a rollercoaster ride ever since. Despite major changes in the work environment, training for postgraduates in oncology has continued with various challenges. We discuss the changes brought about in education, training and assessments for oncology residents.

Evaluation of outcomes in patients of cervical Cancer with lower one third vaginal involvement: A single institutional experience

OBJECTIVE(S)

The objective of this study was to evaluate the clinical outcomes and prognostic factors affecting survival of cervical cancer patients presenting with lower third vaginal involvement.

MATERIALS/METHODS

The patients with histologically proven invasive cervical cancer with clinical FIGO-2009 stage IIIA and IIIB with lower one-third vaginal involvement, treated with radio (chemo) therapy between 2010 and 2016 at our institution were retrospectively analyzed.

RESULTS

There were 118 cervical cancer patients with lower third vaginal involvement with median age of 56.5 years (Range: 33-77 years). Forty-five patients were of FIGO stage IIIA, 73 patients staged as stage IIIB at diagnosis with predominant squamous histology. At a median follow up of 30 months, 12 patients (10.1%) developed local vaginal recurrences and 4 patients (3.3%) had developed loco regional recurrences, 27 patients (23%) developed distant and 2 patients developed loco-regional and distant relapses. The 3- year DFS and OS rates were 61.5% and 69.8% respectively. The 3-year DFS and OS of patients with IIIA was significantly better than IIIB patients (71% vs 56%, p: 0.02 and 76% vs 66%, p: 0.01 respectively) on univariate analysis. Concurrent chemotherapy and absence of persistent disease emerged as independent predictors of survival on multi-variate analysis.

CONCLUSION

The outcome of patients with FIGO IIIA is better than IIIB with lower vaginal involvement. Elderly patients, patients not receiving concomitant chemotherapy and presence of residual disease at BT are associated with poorer outcomes.

FIGO Classification 2018: Validation Study in Patients With Locally Advanced Cervix Cancer Treated With Chemoradiation

PURPOSE

In 2018, the International Federation of Gynecology and Obstetrics (FIGO) proposed a new staging for cervical cancer. The present study was designed to reclassify patients with locally advanced cervix cancer and perform a comparative evaluation with FIGO 2009.

METHODS AND MATERIALS

Patients with locally advanced cervical cancer (stage IB2-IVA) who had baseline cross-sectional imaging and received (chemo-) radiation and brachytherapy were included. Survival outcomes were analyzed according to FIGO 2009. Patients were then reclassified according to FIGO 2018, and TNM classification outcomes were analyzed. FIGO stage and known prognostic factors were included in univariate analysis, and multivariate analysis was performed to investigate the prognostic value of clinical stage.

RESULTS

Six hundred thirty-two patients were included. Overall, 185 (29.3%) patients had pelvic adenopathy, and 51 (8.2%) had positive paraortic nodes. At a median follow-up of 33 months, 116 (18.3%) patients had recurrence. Three-year disease-free survival (DFS) according to FIGO 2009 for stage IB, IIA, IIB, IIIA, IIIB, and IVA was 86%, 91%, 76%, 57%, 65%, and 61%, respectively. The 3-year DFS after restaging according to FIGO 2018 for stage IB, IIA, IIB, IIIA, IIIB, IIIC1, IIIC2, and IVA was 100%, 93%, 84%, 53%, 77%, 74%, 61%, and 61%, respectively. Patients with clinically significant lymphadenopathy had inferior outcomes compared with node-negative patients (62.9% vs 77.8%; P = .002). Patients with ≥3 paraortic nodes had poorer DFS than patients with <3 paraortic lymphadenopathy (13.6% vs 56.3%; P = .001). Furthermore, patients with primary tumor volume >30 cm³ had worse 3-year DFS than those with primary tumor volume ≤30 cm³ (67.4% vs 78.5%; P = .002).

CONCLUSIONS

FIGO 2018 modification is associated with heterogenous outcomes in node-positive patients that are affected by primary tumor and nodal volume. We propose a modification to the existing TNM staging system to allow more robust classification of outcomes.

Standard Chemoradiation and Conventional Brachytherapy for Locally Advanced Cervical Cancer: Is It Still Applicable in the Era of Magnetic Resonance-Based Brachytherapy?

Purpose Recent guidelines recommend magnetic resonance imaging-based brachytherapy (MRBT) for locally advanced cervical cancer. However, its implementation is challenging within the developing world. This article reports the outcomes of patients with locally advanced cervical cancer treated with chemoradiation and point A-based brachytherapy (BT) using x-ray- or computed tomography-based planning. Methods Patients treated between January 2014 and December 2015 were included. Patients underwent x-ray- or computed tomography-based BT planning with an aim to deliver equivalent doses in 2 Gy (EQD2) > 84 Gy₁₀ to point A while minimizing maximum dose received by rectum or bladder to a point or 2 cc volume to < 75 Gy EQD2 and < 90 Gy EQD2, respectively_. The impact of known prognostic factors was evaluated. Results A total of 339 patients were evaluated. Median age was 52 (32 to 81) years; 52% of patients had stage IB2 to IIB and 48% had stage III to IVA disease. There was 85% compliance with chemoradiation, and 87% of patients received four or more cycles. Median point A dose was 84 (64.8 to 89.7) Gy. The median rectal and bladder doses were 73.5 (69.6 to 78.4) Gy₃ and 83 (73.2 to 90.0) Gy₃, respectively. At a median follow-up of 28 (4 to 45) months, the 3-year local, disease-free, and overall survival for stage IB to IIB disease was 94.1%, 83.3%, and 82.7%, respectively. The corresponding rates for stage III to IVA were 85.1%, 60.7%, and 69.6%. Grade III to IV proctitis and cystitis were observed in 4.7% and 0% of patients, respectively. Conclusion This audit demonstrates good 3-year outcomes that are comparable to published MRBT series. Conventional BT with selective use of interstitial needles and MRBT should continue as standard procedures until level-I evidence for MRBT becomes available.

Cisplatin Chemoradiotherapy vs Radiotherapy in FIGO Stage IIIB Squamous Cell Carcinoma of the Uterine Cervix: A Randomized Clinical Trial

Importance

The evidence for concurrent chemoradiotherapy (CT-RT) in International Federation of Gynecology and Obstetrics (FIGO) stage IIIB squamous cell carcinoma of the uterine cervix is not robust. This study reports the final results of a randomized clinical trial of concurrent cisplatin-based CT-RT and radiotherapy alone (RT) in women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix.

Objective

To investigate the benefit of concurrent CT-RT in FIGO stage IIIB squamous cell carcinoma of the uterine cervix.

Design, Setting, and Participants

This phase 3 open-label randomized clinical trial accrued 850 women in Mumbai, India, between July 7, 2003, and September 22, 2011. Of 2121 screened, 850 women with FIGO stage IIIB squamous cell carcinoma of the uterine cervix suitable for concurrent cisplatin chemotherapy were randomly assigned to CT-RT and RT using block randomization (1:1). The data were updated for a minimum follow-up period of 5 years until December 2016. The final analyses were performed in February and March 2017. This single-institution study was conducted at a tertiary cancer center setting.

Interventions

Randomization to receive RT (RT arm), comprising a combination of external beam RT (50 Gy in 25 fractions over 5 weeks) and brachytherapy, or to receive in addition to the same RT concurrent weekly cisplatin chemotherapy (40 mg/m2 per week) (CT-RT arm).

Main Outcomes and Measures

The primary end point was 5-year disease-free survival (DFS), defined as the time between the date of randomization and the date of any recurrence or death (whichever occurred first) in the intent-to-treat population.

Results

This trial included 424 women assigned to CT-RT (mean [SD] age, 49.4 [7.9] years) and 426 women assigned to RT (mean [SD] age, 49.3 [7.9] years). At a median follow-up of 88 months (interquartile range, 61.3-113.1 months), there were 222 recurrences and 213 deaths in the CT-RT arm and 252 recurrences and 243 deaths in the RT arm. The 5-year DFS was significantly higher in the CT-RT arm (52.3%; 95% CI, 52.2%-52.4%) compared with the RT arm (43.8%; 95% CI, 43.7%-43.9%), with a hazard ratio for relapse or death of 0.81 (95% CI, 0.68-0.98) (P = .03). Similarly, the 5-year overall survival (OS) was significantly higher in the CT-RT arm (54.0%; 95% CI, 53.9%-54.1%) compared with the RT arm (46.0%; 95% CI, 45.9%-46.1%), with a hazard ratio for death of 0.82 (95% CI, 0.68-0.98; P = .04). After adjusting for prognostic factors, CT-RT continued to be significantly superior to RT for DFS and OS. There was a higher incidence of acute hematological adverse effects in the CT-RT arm.

Conclusions and Relevance

Chemoradiotherapy using weekly cisplatin results in significantly better DFS and OS compared with RT in women with stage IIIB squamous cell carcinoma of the uterine cervix. This study provides level 1 evidence in the largest clinical trial reported so far in favor of concurrent weekly cisplatin chemotherapy in this setting.

Trial Registration

clinicaltrials.gov Identifier: NCT00193791.

Early toxicity and treatment outcomes of extended field-intensity modulated radiotherapy for cervical cancer patients with para-aortic nodal metastasis

Objective

Extended-field radiotherapy (EFRT) with concurrent chemotherapy represents standard treatment in cervical cancer patients with para-aortic lymph nodal (PALN) metastasis. While EFRT with Intensity Modulated RT (IMRT) has been demonstrated to reduce toxicities, the dose thresholds for minimizing acute toxicity is not clear. The present study was undertaken to report the early toxicity with extended-field intensity-modulated radiotherapy (EF-IMRT) for carcinoma of the cervix in our cohort of patients and determine dose-volume parameters that predict ≥grade II haematological toxicity and diarrhoea.

Methodology

This was a retrospective study of consecutive cervical cancer patients with PALN metastasis treated with EF-IMRT. Patients received rotational IMRT +/- neoadjuvant chemotherapy (NACT) and/or concurrent chemotherapy (45–50 Gy/25#/5 weeks) followed by high-dose rate brachytherapy. Acute haematological and gastrointestinal toxicity (diarrhoea and vomiting) was correlated with doses received by bowel and marrow. Receiver operator characteristics curves were used for deriving thresholds that predict for increased toxicity and tested on univariate and multivariate analysis. Finally, disease free and overall survival (DFS and OS) was calculated.

Results

A total of 43 patients were included. One-fourth of the patients (11/43) received NACT and 88% received concurrent chemotherapy. Within the upfront EF-IMRT cohort, 22.6% and 9.7% patients developed grade ≥III haematological (HT) and gastrointestinal (GI) toxicity respectively, with an increase in HT (≥ grade III HT =67%) in patients receiving NACT (p = 0.007). In the entire cohort bone marrow Volume receiving 10 Gy (V10>) 90% correlated with an increase in ≥ grade III HT (p = 0.05). No dose volume thresholds could be validated for GI toxicity. The OS and DFS at 2 years was 56% and 54%, respectively.

Conclusion

EF-IMRT is a feasible option for cervical cancer patients with PALN involvement and is associated with acceptable grade III toxicity. Future studies need to focus on minimizing HT toxicity.

Impact of inter-observer variations in target volume delineation on dose volume indices for accelerated partial breast irradiation with multi-catheter interstitial brachytherapy

PURPOSE

To investigate dosimetric impact of inter-observer variation in clinical target volume(CTV) delineation for patients undergoing interstitial partial breast brachytherapy.

METHODS

Five radiation oncologists delineated CTV in twenty patients who underwent multi-catheter partial breast brachytherapy. Five treatment plans for each patient were graphically optimized for CTV of all observers and evaluated using coverage index(CI), external volume index(EI), overdose volume index(OI) and conformal index(COIN). In addition, volume enclosed by prescription isodose(V₁₀₀), its spatial concordance(CI_common), mean coverage of all CTVs with common volume of prescription dose(V_{100_common}) and mean CTV coverage for all pairs of observer with common prescription volume of respective pairs(V_{100_pair}) were also computed.

RESULTS

The mean ± standard deviation(SD) of CI and COIN ranged from 0.756 ± 0.076 to 0.840 ± 0.070 and 0.591 ± 0.090 to 0.673 ± 0.06 respectively. When a plan made for CTV of individual observer was evaluated on CTV of all observers, the maximum variations(ρ < 0.05) in the mean CI,COIN,OI and EI were 10.6%,11.4%,10.6% and 72.7% respectively. The observed mean ± SD of V₁₀₀, CI_common of V₁₀₀, CTV coverage with V_{100_common} and V_{100_pair} was 160.7 ± 52.1, 0.70 ± 0.09, 73.1 ± 8.1% and 77.9 ± 7.3% respectively.

CONCLUSION

Inter-observer variation in delineation of CTV showed significant dosimetric impact with mean CTV coverage of 73.1% and 77.9% by common and paired prescription dose volume respectively among all observers.

A Prospective Comparison of Computed Tomography with Transrectal Ultrasonography Assistance and Magnetic Resonance Imaging-Based Target-Volume Definition During Image Guided Adaptive Brachytherapy for Cervical Cancers

PURPOSE

Although magnetic resonance imaging (MRI) represents the gold standard for image guided adaptive brachytherapy (IGABT) for cervical cancer, the majority of brachytherapy (BT) continues to be guided by computed tomography (CT). However, CT seems to overestimate the target-volume definition, and the potential of transrectal ultrasonography (TRUS) needs further evaluation. This prospective, comparative study aimed to evaluate CT-based target contouring with the incorporation of TRUS during BT.

METHODS AND MATERIALS

Patients with locally advanced cervical cancer undergoing magnetic resonance IGABT between January 2013 and March 2014 were included. During the BT procedure, TRUS imaging with central tandem in situ was acquired at 3 representative levels. Reference points/dimensions (D1-D4) of the hypoechoic region on TRUS images with respect to the central tandem were recorded. CT and magnetic resonance BT planning imaging was performed after BT application. The high-risk clinical target volume (HR-CTV) was contoured on CT scans with incorporation of clinical and TRUS imaging findings and was compared with the gold standard MRI-based target approach.

RESULTS

The image sets of 25 patients (International Federation of Gynecology and Obstetrics clinical stage IIB [11; 44%] and IIIB [14; 56%]) were evaluable. The mean (±standard deviation) volumes of HR-CTV on CT and MRI imaging were 39.1 (±20) cm³ and 39 (±19) cm³, respectively (r = 0.92; P < .001)_. A significant correlation was found between the HR-CTV dimensions (width and thickness) of CT and MRI scans at various levels (r = 0.70-0.80; P < .001)_. In addition, the absolute differences in target dimensions between CT and MRI were <0.5 cm. A strong correlation was seen between CT and MRI for patients with medial and lateral parametrial invasion (P < .05) compared with no parametrial disease at BT. Furthermore, the mean differences in HR-CTV width between CT and MRI contours at various levels, irrespective of parametrial involvement, was only 0.1 to 0.4 cm.

CONCLUSIONS

This study suggests that a CT-based target and organ-at-risk delineation using MRI at diagnosis and real-time TRUS information during BT seems comparable with the gold standard MRI-based approach in IGABT for cervical cancer.